Classification of osteoarthritis of the hip is fraught with difficulty Although different patterns of disease are recognised, there is no accepted classification or grading system. We aim to develop a classification system that reflects both the radiological changes, and the local disease process within the joint. After ethical permission and consent tissue was taken from 20 patients undergoing primary hip replacement surgery. Intra-operative tissue samples were taken from each patient and the steady state gene expression of several cytokines (TNF-α, IL1-β, IFN-γ, IL-6, RANKL and OPG) measured quantitatively using Taqman RT-PCR. Relative expression was calculated for each sample using standard curves and normalised to 18S expression. The technique was consistent with high correlations for repeated measures from the same tissue type (κ=0.99) and from different tissue types in the same joint (κ=0.92). Intra-observer (κ=0.93) and inter-observer (κ=0.89) reliability for the technique were also found to be high. Preoperative radiographs were scored by two independent observers and joint space narrowing, cysts, osteophytes and sclerosis noted in each of the DeLee-Charnley zones on the femoral and acetabular side. Based on these scores patients were then classified to either lytic or sclerotic type and subclassified into either hypertrophic or atrophic. Subgroup analysis of cytokine expression by radiographic type was performed. There were statically significant differences in expression of macrophage stimulating cytokines (IL-1γ and OPG) in the lytic group as compared to the sclerotic group (p Our results demonstrate greatly differing patterns of disease within osteoarthritic hip joints. These changes are reflected in radiographic appearances of osteoarthritis. Our proposed classification system can be used grade and classify osteoarthritis in a manner that reflects the disease process.
Introduction Preoperative psychological distress has been reported to predict poor outcome and patient dissatisfaction after total hip replacement (THR). We investigated this relationship in a prospective multi-centre study between January 1999 and January 2002. Methods We recorded the Oxford Hip Score (OHS) and SF36 score preoperatively and up to five years after surgery and a global satisfaction questionnaire at five year follow up for 1039 patients. We dichotomised the patients into the mentally distressed (Mental Health Scale score - MHS Results Both pre and post-operative OHS and SF-36 scores were significantly worse in the distressed group (both p Conclusion Despite having worse absolute values both pre and post operatively, patients with mental distress did not have any less functional gain from THR.
There is wide variation in practice among orthopaedic surgeons regarding the use of skyline tangential patellar radiographs of the patellofemoral joint in patients with anterior knee pain. Various techniques are available for taking such radiographs and numerous radiologic parameters can be measured from them. There is no information as to which knee flexion angle is superior when taking skyline radiographs. The purpose of the current study was to compare the results of skyline radiographs taken at 30°, 50°, and 90° knee flexion. Sixty-seven knees were studied prospectively. All radiographs were made anonymous and then were studied in random order by two observers. Five recognized patellofemoral parameters were recorded. All the parameters studied were measured most reproducibly when measured from the radiograph taken at 30° knee flexion. The parameters were least reproducible when measured from the radiograph taken at 90° knee flexion. In terms of detecting abnormality of the parameters measured, the radiographs taken at 30° and 50° were similar. The radiograph taken at 90° knee flexion detected the fewest abnormalities. Skyline radiographic examination of the patellofemoral joint should be a mandatory part of the investigation of all knee problems. One radiograph, ideally taken at 30° knee flexion, offers the best means of assessing the patellofemoral joint. There is no benefit to requesting multiple images at different angles of knee flexion.
Fifty five primary Ultima® hybrid all-metal (Johnson & Johnson Professional DePuy) total hip replacements (THR) were evaluated prospectively at a mean follow up of 24 months. Patients were selected according to age and activity levels. The mean age at surgery was 58 years (41–69 years). 33 males and 22 females were included in the study. Surgery was carried out for osteoarthritis in 52 patients and for non-union fractured neck of femur, ankylosing spondilitis and post slipped upper femoral epiphysis in the three remaining patients. A single surgeon (the senior author) through the posterior approach carried out surgery. All patients received the Ultima® porous coated titanium shell with a morse taper cobalt chrome liner and double wedge taper polished stem and modular head. Blood metal ion analysis was performed on a cohort of 24 patients using High Resolution Inductively Coupled Plasma Mass Spectrometry, sampling taken pre operatively and then repeated post operatively at 6 months, 1 year and then annually. Clinical results reported at a mean follow-up interval of 2.016 years have been excellent, with no prosthesis to-date requiring revision and no component migration or radiolucuencies being identified on any follow-up radiographs. One patient has died and one is lost to follow-up. The following non-device related complications were reported in the group, 2 (4%) superficial wound infections, 1 (2%) dislocation, 1 (2%) thrombosis, 1 (2%) IT band defect and 2 (4%) impingement. The dislocation was treated with a closed reduction, the position of the component having been judged as satisfactory. The impingement has resolved by one year in both patients. The results of pre and postoperative blood metal ion analysis in a cohort of 24 patients demonstrate some elevated levels, these levels are similar to those previously reported in the literature. The Ultima® hybrid all-metal THR may represent a valuable alternative in the younger, high demand patient.
Sir,
We read with interest the paper by Kim, Kim and Yoon[1][1] in the April 2007 issue entitled ‘Long-term survivorship of the Charnley Elite Plus femoral component in young patients’, particularly in light of several other reports[2][2]–[5][3] of poor radiological outcomes.
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Cartilage destruction in osteoarthritis (OA) is thought to be mediated by two main enzyme families; the matrix metalloproteinases (MMPs) are responsible for cartilage collagen breakdown, whereas enzymes from the 'a disintegrin and metalloproteinase domain with thrombospondin motifs' (ADAMTS) family mediate cartilage aggrecan loss. Tissue inhibitors of metalloproteinases (TIMPs) regulate the activity of these enzymes. Although cartilage destruction in OA might be driven by the chondrocyte, low-grade synovitis is reported in patients with all grades of this disease. Our earlier work profiling these gene families in cartilage identified a number of genes that are regulated in OA, which are hence implicated in the disease process. Because the synovium might contribute to cartilage-matrix destruction in OA, we have extended the screening in the current study. We have profiled MMP, ADAMTS and TIMP genes in both cartilage and synovium from patients with either OA of the hip or a fracture to the neck of femur (NOF), giving a more complete picture of proteolysis in this disease. The four most significantly upregulated genes (P < 0.0001) in OA synovium compared to the fractured NOF are MMP28, ADAMTS16, ADAMTS17 and TIMP2. For MMP9, MMP10, MMP12, MMP17, MMP23, MMP28, ADAMTS4, and ADAMTS9, there is a significant correlation between expression levels in the synovium and cartilage, suggesting similar mechanisms of regulation. Additionally, we have shown that in cartilage the median level of steady-state mRNA for MMP13 is approximately 20-fold higher than MMP28 and approximately 1,500-fold higher than ADAMTS16, with expression of this latter gene approximately 150-fold higher in synovium than cartilage. This study is the most comprehensive analysis of the metzincin family of proteinases in the joint to date and has identified several proteinase genes not previously reported to be expressed or regulated in synovium.
60 out of total series of 643 metal-on-metal hip replacements, carried out over the last nine years, have so far required revision, 13 for peri-prosthetic fracture and 47 for extensive, symptomatic, peri-articular soft-tissue changes. Dramatic corrosion of generally solidly fixed, cemented stems has been observed and is believed to have resulted in the release of high levels of cobalt chrome ions from the stem surface. The contribution of the metal-to-metal articulation is, as yet, unclear. Not including the fracture cases, plain films have demonstrated little or no abnormality to account for patients’ progressive symptoms. MRI scanning, on the other hand, utilising a technique designed to minimise implant artefact, has correlated very closely with findings at the time of revision surgery. The histological changes, typified by extensive lymphocytic infiltration and a severe vasculitis leading to, in some cases, extensive tissue necrosis are demonstrated and discussed. The failure of any of the existing protective mechanisms or regulatory restrictions to identify and limit the exposure of large numbers of patients to unsatisfactory implants has again been demonstrated.
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